Healthcare Provider Details

I. General information

NPI: 1134591068
Provider Name (Legal Business Name): LISA KERES IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 COTTAGE ST NE
SALEM OR
97301-7126
US

IV. Provider business mailing address

1895 COTTAGE ST NE
SALEM OR
97301-7126
US

V. Phone/Fax

Practice location:
  • Phone: 425-314-0189
  • Fax:
Mailing address:
  • Phone: 425-314-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number202104736RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-64979
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: